STATE OF CALIFORNI A SCHEDULE A-4 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30,2009 Provider No.: ZZT30107H Audited Medi-Cal Cost Per Day 1. Medi-Cal Cost of Covered Services (Schedule 3, Line 8) $ 2. Less: Medi-Cal Administrative Day Cost (Schedule 4A, Lines 28 and 31) 3. Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 minus Line 2) $ 0 4. Total Audited Medi-Cal Days (Schedules 4, 4A, and 4B, excludes Administrative Days) 5. Audited Medi-Cal Cost Per Day (Line 3 ÷ Line 4) $ 0.00 10 % Cost Reduction For Services From 07/01/08 Through 06/30/2009 6. Audited Medi-Cal Days of Service from 07/01/08 - 06/30/2009 (excludes Administrative Days) 7. Audited Medi-Cal Cost Per Day for 07/01/08 - 06/30/2009 (Line 5 X Line 6) $ 0 8. 10% Cost Reduction for 07/01/08 - 06/30/2009 (Line 7 X 10%) $ 0 (To Schedule A, Ln 4) 10% REDUCTION FOR SERVICES FROM JULY 1, 2008 THROUGH JUNE 30, 2009 COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT HFPAs WITH LESS THAN 3 HOSPITALS AB 5 This is trial version www.adultpdf.com STATE OF CALIFORNI A SCHEDULE A-5 (RURAL HEALTH ) PROGRAM: NONCONTRAC T Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTE R JUNE 30,2009 Provider No. ZZT30107H Audited Medi-Cal Cost Per Da y 1. Medi-Cal Cost of Covered Services (Schedule 3, Line 8) $ 2. Less: Medi-Cal Administrative Day Cost (Schedule 4A, Lines 28 and 31) 3. Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 minus Line 2) $ 0 4. Total Audited Medi-Cal Days (Schedules 4, 4A, and 4B, excludes Administrative Days) 5. Audited Medi-Cal Cost Per Day (Line 3 ÷ Line 4) $ 0.00 10% Cost Reduction For Services From 07/01/08 Through 10/31/0 8 6. Audited Medi-Cal Days of Service from 07/1/08 - 10/31/08 (excluding Administrative Days) 7. Audited Medi-Cal Cost Per Day for 07/01/08 - 10/31/08 (Line 5 X Line 6) $ 0 8. 10% Cost Reduction for 07/01/08 - 10/31/08 (Line 7 X 10%) $ 0 (To Schedule A, Ln 5) 10% REDUCTION FOR SERVICES FROM JULY 1, 2008 THROUGH OCTOBER 31, 2008 COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT RURAL HEALTH HOSPITALS AB 5 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 1 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No. ZZT30107G REPORTED AUDITED 1. Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 8,960,121 $ 8,991,725 2. Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0 3. Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ N/A 4. $0 $0 5. TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 8,960,121 $ 8,991,725 6. Interim Payments (Adj 29) $ (8,260,723) $ (8,481,358) 7. Balance Due Provider (State) $ 699,398 $ 510,367 8. Duplicate Payments (Adj ) $ $ 0 9. AB 5 $ (926,000) $ (898,972) 10. $0 $0 11. TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ (226,602) $ (388,605) (To Summary of Findings) COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 2 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No. ZZT30107G REPORTED AUDITED REASONABLE COST OF MEDI-CAL INPATIENT SERVICES 1. Cost of Covered Services (Schedule 3) $ 9,043,166 $ 9,075,575 CHARGES FOR MEDI-CAL INPATIENT SERVICES 2. Inpatient Routine Service Charges (Adj 28) $ 10,287,523 $ 12,689,639 3. Inpatient Ancillary Service Charges (Adj 28) $ 25,001,239 $ 26,028,225 4. Total Charges - Medi-Cal Inpatient Services $ 35,288,762 $ 38,717,864 5. Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) * $ 26,245,596 $ 29,642,289 6. Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0 (To Schedule 1) * If charges exceed reasonable cost, no further calculation necessary for this schedule. COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 3 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No. ZZT30107G REPORTED AUDITED 1. Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 4,634,401 $ 4,636,499 2. Medi-Cal Inpatient Routine Services (Schedule 4) $ 4,408,765 $ 4,439,076 3. Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0 4. $0 $0 5. $0 $0 6. SUBTOTAL (Sum of Lines 1 through 5) $ 9,043,166 $ 9,075,575 7. Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0 8. SUBTOTAL $ 9,043,166 $ 9,075,575 (To Schedule 2) 9. Coinsurance (Adj 29) $ (83,045) $ (9,129) 10. Patient and Third Party Liability (Adj 29) $ 0 $ (74,721) 11. Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 8,960,121 $ 8,991,725 (To Schedule 1) COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 4 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No. ZZT30107G GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED INPATIENT DAYS 1. Total Inpatient Days (include private & swing-bed) (Adj 24) 34,331 35,518 2. Inpatient Days (include private, exclude swing-bed) 34,331 35,518 3. Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4. Semi-Private Room Days (exclude swing-bed) (Adj ) 34,331 34,331 5. Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6. Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7. Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8. Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9. Medi-Cal Days (excluding swing-bed) (Adj 26) 3,884 4,001 SWING-BED ADJUSTMENT 17. Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 0.00 $ 0.00 18. Medicare NF Swing-Bed Rates after Dec 31(Adj ) $ 0.00 $ 0.00 19. Medi-Cal NF Swing-Bed Rates through July 31(Adj ) $ 0.00 $ 0.00 20. Medi-Cal NF Swing-Bed Rates after July 31(Adj ) $ 0.00 $ 0.00 21. Total Routine Serv Cost (Sch 8, Line 25, Col 27) $ 28,112,680 $ 27,321,085 22. Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23. Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24. Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25. Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26. Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27. Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 28,112,680 $ 27,321,085 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28. Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 115,992,479 $ 115,992,479 29. Private Room Charges (excluding swing-bed charges) $ 0 $ 0 30. Semi-Private Room Charges (excluding swing-bed charges) $ 115,992,479 $ 115,992,479 31. Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0.242366 $ 0.235542 32. Average Private Room Per Diem Charge (L 29 / L 3) $ 0.00 $ 0.00 33. Average Semi-Private Room Per Diem Charge (L 30 / L 4) $ 3,378.65 $ 3,378.65 34. Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 0.00 $ 0.00 35. Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 0.00 $ 0.00 36. Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37. Inpatient Rout Cost Net of Swing-Bed & Prvt Rm (L 27 minus L 36) $ 28,112,680 $ 27,321,085 PROGRAM INPATIENT OPERATING COST 38. Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 818.87 $ 769.22 39. Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3,180,491 $ 3,077,649 40. Cost Applicable to Medi-Cal (Sch 4A) $ 1,228,274 $ 1,361,427 41. Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0 42. TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39,40 & 41) $ 4,408,765 $ 4,439,076 ( To Schedule 3 ) MEDI-CAL INPATIENT ROUTINE SERVICE COST COMPUTATION OF This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 4A PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No. ZZT30107G SPECIAL CARE AND/OR NURSERY UNITS REPORTED AUDITED NURSERY 1. Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) $ 2,462,658 $ 2,492,392 2. Total Inpatient Days (Adj 24) 6,834 6,440 3. Average Per Diem Cost $ 360.35 $ 387.02 4. Medi-Cal Inpatient Days (Adj 26) 3,291 3,390 5. Cost Applicable to Medi-Cal $ 1,185,912 $ 1,311,998 INTENSIVE CARE UNIT 6. Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 6,634,315 $ 6,398,014 7. Total Inpatient Days (Adj 24) 3,602 3,508 8. Average Per Diem Cost $ 1,841.84 $ 1,823.84 9. Medi-Cal Inpatient Days (Adj 26) 23 26 10. Cost Applicable to Medi-Cal $ 42,362 $ 47,420 CORONARY CARE UNIT 11. Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) $ 0 $ 0 12. Total Inpatient Days (Adj ) 0 0 13. Average Per Diem Cost $ 0.00 $ 0.00 14. Medi-Cal Inpatient Days (Adj ) 0 0 15. Cost Applicable to Medi-Cal $ 0 $ 0 NEONATAL INTENSIVE CARE UNIT 16. Total Inpatient Routine Cost (Sch 8, Line 28, Col 27) $ 0 $ 0 17. Total Inpatient Days (Adj ) 0 0 18. Average Per Diem Cost $ 0.00 $ 0.00 19. Medi-Cal Inpatient Days (Adj ) 0 0 20. Cost Applicable to Medi-Cal $ 0 $ 0 SURGICAL INTENSIVE CARE UNIT 21. Total Inpatient Routine Cost (Sch 8, Line 29, Col 27) $ 0 $ 0 22. Total Inpatient Days (Adj ) 0 0 23. Average Per Diem Cost $ 0.00 $ 0.00 24. Medi-Cal Inpatient Days (Adj ) 0 0 25. Cost Applicable to Medi-Cal $ 0 $ 0 ADMINISTRATIVE DAYS (JULY 1, 2008 THROUGH JULY 31, 2008) 26. Per Diem Rate (Adj 25) $ 0.00 $ 318.19 27. Medi-Cal Inpatient Days (Adj 25) 0 3 28. Cost Applicable to Medi-Cal $ 0 $ 955 ADMINISTRATIVE DAYS (AUGUST 1, 2008 THROUGH JUNE 30, 2009) 29. Per Diem Rate (Adj 25) $ 0.00 $ 351.26 30. Medi-Cal Inpatient Days (Adj 25) 0 3 31. Cost Applicable to Medi-Cal $ 0 $ 1,054 32. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,28,31) $ 1,228,274 $ 1,361,427 (To Schedule 4) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 4B PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No. ZZT30107G SPECIAL CARE UNITS REPORTED AUDITED 1. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0 2. Total Inpatient Days (Adj ) 0 0 3. Average Per Diem Cost $ 0.00 $ 0.00 4. Medi-Cal Inpatient Days (Adj ) 0 0 5. Cost Applicable to Medi-Cal $ 0 $ 0 6. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0 7. Total Inpatient Days (Adj ) 0 0 8. Average Per Diem Cost $ 0.00 $ 0.00 9. Medi-Cal Inpatient Days (Adj ) 0 0 10. Cost Applicable to Medi-Cal $ 0 $ 0 11. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0 12. Total Inpatient Days (Adj ) 0 0 13. Average Per Diem Cost $ 0.00 $ 0.00 14. Medi-Cal Inpatient Days (Adj ) 0 0 15. Cost Applicable to Medi-Cal $ 0 $ 0 16. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0 17. Total Inpatient Days (Adj ) 0 0 18. Average Per Diem Cost $ 0.00 $ 0.00 19. Medi-Cal Inpatient Days (Adj ) 0 0 20. Cost Applicable to Medi-Cal $ 0 $ 0 21. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0 22. Total Inpatient Days (Adj ) 0 0 23. Average Per Diem Cost $ 0.00 $ 0.00 24. Medi-Cal Inpatient Days (Adj ) 0 0 25. Cost Applicable to Medi-Cal $ 0 $ 0 26. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0 27. Total Inpatient Days (Adj ) 0 0 28. Average Per Diem Cost $ 0.00 $ 0.00 29. Medi-Cal Inpatient Days (Adj ) 0 0 30. Cost Applicable to Medi-Cal $ 0 $ 0 31. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 0 $ 0 (To Schedule 4) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 5 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No: ZZT30107G RATIO COST TO CHARGES ANCILLARY COST CENTERS 37.00 Operating Room $ 11,051,806 $ 106,344,799 0.103924 $ 5,363,295 $ 557,377 37.01 Gastro Intestinal Service 443,025 1,170,465 0.378504 19,482 7,374 37.20 Cardicac Cath Lab 2,706,650 30,631,594 0.088361 198,769 17,564 38.00 Recovery Room 0 0 0.000000 0 0 39.00 Delivery Room and Labor Room 7,254,402 19,550,277 0.371064 6,684,146 2,480,245 40.00 Anesthesiology 346,015 36,937,085 0.009368 2,456,948 23,016 41.00 Radiology - Diagnostic 8,300,061 52,095,736 0.159323 202,086 32,197 41.01 CT Scan and MRI 1,870,488 36,694,158 0.050975 444,536 22,660 43.00 Radioisotope 1,777,070 16,706,218 0.106372 31,812 3,384 44.00 Laboratory 8,154,976 73,924,038 0.110316 2,888,211 318,615 44.01 Pathological Lab 0 0 0.000000 0 0 46.00 Whole Blood & Packed Red Blood 1,987,954 4,811,561 0.413162 256,179 105,843 47.00 Blood Storing and Processing 0 0 0.000000 0 0 48.00 Intravenous Therapy 180,685 625,923 0.288670 0 0 49.00 Respiratory Therapy 3,502,733 8,505,764 0.411807 62,023 25,542 50.00 Physical Therapy 2,800,043 10,407,977 0.269029 204,914 55,128 51.00 Occupational Therapy 1,235,588 4,038,475 0.305954 5,612 1,717 52.00 Speech Pathology 0 0 0.000000 0 0 53.00 Electrocardiology 2,533,069 11,279,552 0.224572 14,330 3,218 54.00 Electroencephalography 113,498 267,478 0.424326 2,812 1,193 55.00 Medical Supplies Charged to Patients 9,262,769 35,024,732 0.264464 1,168,432 309,008 55.01 Medical Supplies Chrg. Pat. - IMP 10,610,140 37,696,037 0.281466 148,654 41,841 56.00 Drugs Charged to Patients 8,085,390 79,938,761 0.101145 5,375,341 543,688 57.00 Renal Dialysis 381,009 655,266 0.581457 2,915 1,695 58.00 ASC (Non-Distinct Part) 0 0 0.000000 0 0 59.00 Ultrasound 694,280 7,805,337 0.088949 217,238 19,323 59.02 0 0 0.000000 0 0 59.03 0 0 0.000000 0 0 60.00 Clinic 1,793,163 4,012,970 0.446842 0 0 60.01 Other Clinic Services 0 0 0.000000 0 0 61.00 Emergency 10,105,355 43,030,654 0.234841 280,490 65,871 62.00 Observation Beds 0 1,747,028 0.000000 0 0 71.00 Home Health Agency 16,300,486 0 0.000000 0 0 89.00 Utilization Review 980,387 0 0.000000 0 0 93.00 Hospice 2,970,702 0 0.000000 0 0 0 0 0.000000 0 0 0 0 0.000000 0 0 0 0 0.000000 0 0 TOTAL $ 115,441,744 $ 623,901,885 $ 26,028,225 $ 4,636,499 (To Schedule 3) * From Schedule 8, Column 27 ANCILLARY MEDI-CAL (Adj ) COSTCHARGES (From Schedule 6) MEDI-CAL SCHEDULE OF MEDI-CAL ANCILLARY COSTS TOTAL COST * CHARGES TOTAL ANCILLARY This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 6 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 Provider No: ZZT30107G ANCILLARY CHARGES 37.00 Operating Room $ 5,144,446 $ 218,849 $ 5,363,295 37.01 Gastro Intestinal Service 17,965 1,517 19,482 37.20 Cardicac Cath Lab 176,410 22,359 198,769 38.00 Recovery Room 0 39.00 Delivery Room and Labor Room 6,573,360 110,786 6,684,146 40.00 Anesthesiology 2,376,637 80,311 2,456,948 41.00 Radiology - Diagnostic 189,731 12,355 202,086 41.01 CT Scan and MRI 424,407 20,129 444,536 43.00 Radioisotope 31,812 31,812 44.00 Laboratory 2,710,437 177,774 2,888,211 44.01 Pathological Lab 0 46.00 Whole Blood & Packed Red Blood 230,593 25,586 256,179 47.00 Blood Storing and Processing 0 48.00 Intravenous Therapy 0 49.00 Respiratory Therapy 59,233 2,790 62,023 50.00 Physical Therapy 199,864 5,050 204,914 51.00 Occupational Therapy 5,087 525 5,612 52.00 Speech Pathology 0 53.00 Electrocardiology 12,980 1,350 14,330 54.00 Electroencephalography 2,812 2,812 55.00 Medical Supplies Charged to Patients 1,114,072 54,360 1,168,432 55.01 Medical Supplies Chrg. Pat. - IMP 145,677 2,977 148,654 56.00 Drugs Charged to Patients 5,111,707 263,634 5,375,341 57.00 Renal Dialysis 2,915 2,915 58.00 ASC (Non-Distinct Part) 0 59.00 Ultrasound 197,001 20,237 217,238 59.02 0 59.03 0 60.00 Clinic 0 60.01 Other Clinic Services 0 61.00 Emergency 274,093 6,397 280,490 62.00 Observation Beds 0 71.00 Home Health Agency 0 89.00 Utilization Review 0 93.00 Hospice 0 0 0 0 TOTAL MEDI-CAL ANCILLARY CHARGES $ 25,001,239 $ 1,026,986 $ 26,028,225 (To Schedule 5) ADJUSTMENTS TO MEDI-CAL CHARGES REPORTED ADJUSTMENTS AUDITED (Adj 27) This is trial version www.adultpdf.com . Provider (State) $ (226,602) $ (388,605) (To Summary of Findings) COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 2 PROGRAM: NONCONTRACT Provider. (Sum of Lines 39,40 & 41) $ 4,408 ,76 5 $ 4,439, 076 ( To Schedule 3 ) MEDI-CAL INPATIENT ROUTINE SERVICE COST COMPUTATION OF This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE. (Sum of Lines 5,10,15,20,25,28,31) $ 1,228, 274 $ 1,361,4 27 (To Schedule 4) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE